“Objective: To compare screening costs per relevant target finding of CRC [colorectal cancer] screening (that is, CRC, advanced adenoma, or sessile serrated polyp ≥1 cm) for FIT [fecal immunochemical tests], MSDT [multitarget stool DNA tests (e.g., Cologard [Exact Sciences])], and N-G [next-generation] MSDT.
Methods and Findings: [..] We summed the test costs for all participants, including costs for follow-up colonoscopies, and we divided those costs by number of participants with detected CRC or any advanced neoplasia (CRC, advanced adenoma, or sessile serrated polyp ≥1 cm). Furthermore, we calculated costs per additional early-detected CRC case or any advanced neoplasia with MSDT-based and N-G MSDT–based screening compared with FIT-based screening.
[..] In this base-case analysis, we assumed 60% uptake of colonoscopy after a positive fecal test result. The screening costs per detected advanced neoplasia case or per early-detected CRC case are approximately 7- to 9-fold higher for MSDT-based and N-G MSDT–based screening than for FIT-based screening. Costs per additional early-detected CRC case compared with FIT-based screening are more than $700 000 for both MSDT- and N-G MSDT–based screening, and these costs are approximately 40 and 30 times higher, respectively, than costs for the FIT-detected CRC cases.
[..] For the lower uptake rate of screening colonoscopy [authors performed a sensitivity analysis down to 30% colonoscopy uptake after a positive fecal test], all screening costs—and in particular those for MSDT-based and N-G MSDT–based screening—would be higher than in the base-case analysis, resulting in even larger ratios of costs per detected case of CRC or advanced neoplasia compared with FIT-based screening. In addition, the incremental costs for early detection of 1 additional CRC case compared with FIT-based screening would increase to more than $1.4 million for the MSDT and more than $1.5 million for the N-G MSDT. With colonoscopy follow-up rates of positive fecal test results as high as 90%, the detection rates per CRC case would be somewhat lower, but the incremental costs for early detection of 1 additional CRC case compared with FIT-based screening would still be above $500 000 for both the MSDT and the N-G MSDT. Even if the costs per test for MSDT and N-G MSDT were lowered to $100—that is, less than 20% of the current costs—the cost per additional case of CRC or advanced neoplasia detected by MSDT or N-G MSDT compared with FIT would still be manyfold higher than costs for FIT-detected cases of CRC and advanced neoplasia.
Discussion: [..] our results indicate that there would be much to gain if the current trends of decreasing FIT use rates and increasing MSDT use rates in the United States could be reversed. The main argument in favor of MSDT and N-G MSDT has been their higher sensitivity compared with FIT. However, as previously shown, essentially the same sensitivity and specificity could be achieved at no incremental cost by lowering the FIT positivity threshold. The FIT cutoffs used in different countries vary widely, and the current practice in the United States that hinders use of quantitative information from FITs and flexibility in defining the positivity threshold should be reconsidered.”
Full article, H Brenner, T Seum, T Heisser and M Hoffmeister. Annals of Internal Medicine, 2025.5.13